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Rear-Facing Car Seats Advised at Least to Age of 2

Toddlers are usually switched from rear-facing to forward-facing car seats right after their first birthday — an event many parents may celebrate as a kind of milestone.

But in a new policy statement, the nation’s leading pediatricians’ group says that is a year too soon.

The advice from the American Academy of Pediatrics, issued Monday, is based primarily on a 2007 University of Virginia study finding that children under 2 are 75 percent less likely to suffer severe or fatal injuries in a crash if they are facing the rear.

“A baby’s head is relatively large in proportion to the rest of his body, and the bones of his neck are structurally immature,” said the statement’s lead author, Dr. Dennis R. Durbin, scientific co-director of the Center for Injury Research and Prevention at the Children’s Hospital of Philadelphia. “If he’s rear-facing, his entire body is better supported by the shell of the car seat. When he’s forward-facing, his shoulders and trunk may be well restrained, but in a violent crash, his head and neck can fly forward.”

The new policy statement also advises that older children should ride in a belt-positioning booster seat until they are 4 feet 9 inches tall, and 8 to 12 years old. A booster seat allows the vehicle’s lap and shoulder seat belt to fit properly, meaning the lap portion of the belt fits low across the hips and pelvis, and the shoulder portion fits across the middle of the shoulder and chest.

“Our recommendations are meant to help parents move away from gospel-held notions that are based on a child’s age,” Dr. Durbin said. “We want them to recognize that with each transition they make, from rear-facing to forward-facing, to booster seats, there is a decline in the safety of their child. That’s why we are urging parents to delay these transitions for as long as possible.”

Safety advocates applaud the new policy, but say the transition from rear- to forward-facing is usually the one that parents are least willing to delay.

“People cheer when they turn their kid around at one year, but hopefully some day they’ll cheer at how long they were able to keep their child rear-facing,” said Debbi Baer, a labor and delivery nurse in Baltimore who has been a car safety advocate for children for more than 30 years.

The academy’s previous policy, from 2002, said it was safest for infants and toddlers to ride facing the rear, and cited 12 months and 20 pounds as the minimum requirements for turning the car seat forward. But Ms. Baer, a certified child passenger safety technician, said parents tended to take that as a hard and fast rule.

“A lot of parents consider turning the car seat around as another developmental milestone that shows how brilliant and advanced their child is,” she said, “and they don’t realize that it’s making their child less safe.”

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<b> NEW RECOMMENDATION </b> A study found that children under 2 are 75 percent less likely to suffer severe or fatal injuries in a crash if they face backward.Credit
The Children's Hospital of Philadelphia

Ms. Baer says the evidence from other countries is compelling: Sweden, for instance, where children face the rear until age 4, has the world’s lowest highway fatality rate for children under 6.

Seven years ago, Ed Weissberg and his wife, Edda, of Baltimore, took Ms. Baer’s advice, and say it saved their daughter Renana’s life.

The couple and their three children were traveling north on Interstate 95 when they were broadsided by a car that had had a blowout. Their minivan flipped into the air, sailed over three lanes of traffic and landed on the shoulder, upside down.

“The E.M.T.’s told me later that as soon as they saw our car, they were ready to take out our bodies,” said Mr. Weissberg, who now lives in Israel with his family. Instead, they found the entire family nearly unscathed, with all three children suspended upside down, still securely strapped in their car seats.

“People thought we were crazy for keeping our 2-year-old rear-facing, but if she had been facing forward, she wouldn’t be alive today,” he said.

Dr. Alisa Baer, a pediatrician at Morgan Stanley Children’s Hospital in New York (and Debbi Baer’s daughter), said Renana Weissberg’s case was far from unique.

“It’s a horrible term,” she said, “but E.M.T.’s call the rear-facing seat ‘the orphan seat’ because in a bad car accident, that child is often the only one who survives.”

Until recently, most car seats that could be turned to face the rear did not accommodate children weighing more than 20 pounds. Today, however, the limits are closer to 30 to 35 pounds, and a few go to 45 pounds.

Dr. Baer said she felt so strongly that if a parent wants to install a forward-facing seat for a child younger than 2, “I tell them, ‘If you really want to make a stupid decision for your child, you can do it, but I’m not going to help you.’ ”

She noted that parents often told her that their 2-year-olds would be uncomfortable with their legs squashed against the back of the seat, and that they might be more likely to break their legs in a crash. Neither is true, she said.

“I always reassure parents that just because it looks uncomfortable to you doesn’t mean that it is for a child,” said Dr. Baer.

A version of this article appears in print on March 22, 2011, on page D5 of the New York edition with the headline: Keep Facing Backward for Child Safety. Order Reprints|Today's Paper|Subscribe